What Price Health Care?
Mickey Kaus, further explicating his views on entitlement policy seems fundamentally driven by the idea that a move to universal health care would be very expensive and likely to result in "a larger tax burden than citizens are willing to bear." You can see why one might think that, but I'm not at all certain it's correct. The US government currently spends a phenomenal sum of money on health care by world standards which strongly suggests to me that there are significant savings that could be achieved through reforms.
What's more, the large number of people who currently get health care through their employers are already used to seeing a slice of money deducted from their paychecks to cover health insurance. I feel like people in that situation (say, me) wouldn't even really notice if that deduction were relabeled a "health insurance tax" rather than a "premium." The uninsured working poor surely wouldn't mind since any reasonable system would be giving them significantly more in benefits than they'd be paying in taxes. The folks likely to resent the change are the relatively small number of youngish, reasonably healthy people who currently don't have employer-sponsored health care and don't especially mind not having it since they don't have much in the way of health expenses. That's a not-entirely-trivial group of people, but it's a distinct minority and not a powerful political lobby.
All of which turns back to the basic point that when you're talking about universal health care you're not really talking about increasing the aggregate resources poured into American health care. There's already tons of money being spent on it. You're talking about redistributing the spending somewhat from richer to less-rich people and altering the path through which the money flows. If you believe (as I do) that a government-run insurance pool could realize significant savings vis-a-vis a series of private sector ones, then I think there's plenty of reason to be optimistic about ability to pay. The significant financial challenge has to do with covering the bills for old people, but that challenge exists one way or another thanks to Medicare (and the basic reality that senior citizens are largely uninsurable in the private sector) and has relatively little to do with whether or not we can afford to bring universal coverage to the under-65 crowd.
And this will be the trick to selling such a system: Americans have been so bombarded by anti-tax messages over the past 20 years that even otherwise progressive people won't vote for anyone who will "raise my taxes." The message has to be "lower healthcare costs", (which will be true if we do it right), and reformers will need some smart non-wonky frames to counter the no-new-taxes knee-jerk mindset.
The two biggest obstacles to HC reform are the anti-tax mantra, and the entrenched interests making money off the current mess.
August 21, 2006 10:15 AM | Reply | Permalink
I agree. And one of the things that would really help would be if even the liberal pundits would not hold views like:
Of course, liberal pundits should be free to express their actual beliefs. But it is just a plainly wrong view, and terribly unhelpful. I hear Mickey did great work once upon a time, but that is no longer the case.
August 21, 2006 1:25 PM | Reply | Permalink
My great problem with the idea can be summed up in an old bit of wisdom:
"To the man who only has a hammer, everything looks like a nail."
The government has a "hammer", and it's the ability to coerce people. Really, that's the only thing the government can bring to the solution of any problem, that's not available in the private sector.
Now, in some limited circumstances, coercion really is appropriate. Sometimes you really ARE presented with a "nail", in other words.
But, again, the government has a hammer, and when presented with a screw, pounds on it. When presented with a pop rivet, pounds on it. When presented with a thumb, pounds on it. When presented with nothing... goes looking for something to pound on.
The government reflexively coerces where unnecessary, or even utterly inappropriate. Heck, that's a lot of what got Hillarycare in trouble. The details started to emerge, and it was, like, if this plan is so good, why all the fines and jail sentences for trying to get treatment outside it?
Because fines and jail sentences are what the government does. Because when you decide to do something through the government, you've already decided that you're going to take people's choices away from them.
Sorry, let's find a fix, if one is needed, that doesn't involve throwing people in jail if they don't obey.
August 21, 2006 6:04 PM | Reply | Permalink
You make some good points about things that are not always obvious. I support universal coverage, not employer-based, but not necessarily single-payer. The Federal Employee Health Plan, with a consumer-based agent that offers multiple plans at various costs and benefits, is a workable model. I do believe that there is one necessary part that can be considered coercive, but with a number of caveats.
Much as liability insurance is a requirement to drive, I do consider that participation, with an appropriate First Amendment exception for people such as Christian Scientists, is mandatory. Now, "mandatory" doesn't necessarily mean that those unable to work or unable to find work have to come up with their premium. Much as Medicaid and Medicare operate, there would be tax-based credits to be extended to an appropriate payor cooperative. Universal coverage also does away with the unfunded mandate of EMTALA. I would ban cost shifting and audit providers to verify it is not happening.
Any healthcare program has to "ration", and this sometimes is even beneficial to patients. In medicine, there is a cynical acronym, VOMIT, standing for "Victim Of Modern Imaging Technology": the situation where clinicians don't do sufficient history and physical, send someone off to CT or other advanced scan, and then treat an abnormality in the scan that suggests a nonexistent disease in the patient. CT and X-ray do involve radiation exposure that, done too often, is a hazard. MRI and ultrasound do not. Automatically ordering CTs, especially some of the most sensitive but higher radiation, is not a good idea.
Rather emphatically, however, I believe it should be possible to self-pay outside the system. Several physician friends, including a specialist in evidence-based medicine, observe that this is not just the aversion to punitive measures in the Clinton plan, but a cross-check on mainstream medicine. Cosmetic surgery generally has been self-pay, and the market did introduce cost-efficiencies in appropriate outpatient surgery.
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Howard
*equal opportunity offense to both extremes*
August 21, 2006 6:33 PM | Reply | Permalink
What about saving money by not subsidizing the socialized health care of the rest of the developed world?
The drug companies "claim" we pay for the research and development and that is why drugs are more expensive here.
That is a subsidy to others if that is true.
Their mothers and grandmothers get inexpensive drugs while ours do not.
Also, what about workman's compensation for on the job accidents, that is a single payer system in use now.
Do not judge it as working or not as it is intended to not work at least in Florida.
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Today, are we searching for I deals or Ideals?
-Thinking
August 21, 2006 7:09 PM | Reply | Permalink
Having had direct experience in clinical trials, I know drug R&D is expensive. Unfortunately, the marketing budgets of most pharmaceutical firms have, for some time, exceeded their R&D budgets.
There are delicate balances among First Amendment rights, even though the rights of corporations in this area are controversial. Yes, there is FDA approval of consumer advertising, especially of prescription drugs, but, looking through the lens of knowing pharmacology, the ads often stay just on the edge of being outright misleading. There's no clear consensus if advertising is causing a diversion of healthcare resources either to explain that "Panaceacin" is inappropriate, or that busy clinicians will write wasteful prescriptions that are unlikely to have any benefit.
I have seen some quite decent websites sponsored by pharmaceutical companies, that actually inform rather than go for the momentary appeal of TV advertising. Still, these seem to be a small portion of the budget -- and I wonder if the patients motivated to do web research would get the answers anyway in independent sites.
Again, I don't have a good answer. There are accurate sites intended for medical professionals, but these often can be confusing for someone without the appropriate background.
--
Howard
*equal opportunity offense to both extremes*
August 21, 2006 7:22 PM | Reply | Permalink
MY said:
The US government currently spends a phenomenal sum of money on health care by world standards which strongly suggests to me that there are significant savings that could be achieved through reforms.
Any such savings would come at the expense of rich and powerful interests which would resent it bitterly. So I suspect such reforms are unlikely to pass rendering the savings illusory. More likely said rich and powerful interests would sneak obscure provisions into "reform" legislation which would enable them to grab even more. Unless you have some practical way to defeat this dynamic I expect any move to universal health care will be accompanied by massive increases in spending and any hopes to the contrary are just wishful thinking.
August 21, 2006 8:37 PM | Reply | Permalink
You read the Coulter groupie Mickey Kaus?
Why?
August 21, 2006 9:12 PM | Reply | Permalink
Re: What's more, the large number of people who currently get health care through their employers are already used to seeing a slice of money deducted from their paychecks to cover health insurance.
Not necessarily. To be sure employer paid health care premiums do come out of overall employee compensation, but people do not ever see that money in their check and so assume they are getting "free" health care. Indeed, the higher income the job the more likely it is that the employer is picking up the tab directly fof 100% of the premium. So suddenly you would have a lot of middle and upper income people paying for their health insurance with what they do consider their own money for the first time.
August 22, 2006 4:20 PM | Reply | Permalink
Just to make it clear, I don't think that universal health care by itself requires a "larger tax burden than citizens are willing to bear." I do think that universal health care will add some significant government expense (especially if it's decent care and not a two-tiered or five-tiered system). And I think this added government expense, on top of all our other entitlements, including Social Security is what will require the too-large tax burden. We're not coming close to covering the current entitlement structure as it is, without universal health care.
If something has to give shouldn't it be Social Security's checks-to-the-rich feature, not health care? That's my point, anyway, which is elaborated in tedious detail in this blog response.
August 23, 2006 3:03 AM | Reply | Permalink
Now, if you want to talk about raising the earnings cap on the FICA tax, I'm all ears.
August 23, 2006 10:49 AM | Reply | Permalink
Don't we already have "universal health care"?
I thought we were just arguing about -- as the wit once had it -- the price.
August 23, 2006 11:14 AM | Reply | Permalink
It seems that many are out of touch with the "new realities". The dollar is "over", and discussions like this one are soooo....2000. They are irrelevant. The only thing propping up the dollar is Japan, for more than ten years, and lately China, printing their own currencies out of "thin air", and trading that "new money" for the US dollars that flow in to their exporters. By printing money out of "thin air", they dilute the exchange value of their own currencies, keeping them lower, in relation to the dollar, than they possibly should be, and they purchase US T-Bills with those dollars, keeping US borrowing costs lower, since public and government borrowers in the US all compete for a theoretically finite pool of lenders who will settle for 6 percent interest rates in this currency "ponzi" scheme.
People.... this is over. Before tax "reform", in 2004, an economist's study, published on the fed's own website, indicates that the bottom 50 percent of the US population controls only 2.5 percent of the wealth. The top 10 percent controls 70 percent, and the next 40 percent, just 27-1/2 percent.
These wealth "holders" now benefit. via tax "reform", to an even larger grip on the "pie". They finance and control the political agenda, and they will escape much of the economics induced misery that the people they got elected, are causing. They will never allow the legislation that you want to see, or even the shift in party control that it would require.
There is no money to "shift" from SSI to universal healthcare. There is note even enough stable purchasing power in the dollar, going forward, to even guarantee the funding of the US military at current levels.
Here is why:
....let us review the federal spending for the last eleven years. Six years of democratic control of the presidency, with the republicans in charge of the house, and 4 yrs. and 11 months of total republican control/budget management:
08/18/2006 $8,500,932,047,599.16
09/28/2001 $5,807,463,412,200.06
09/29/1995 $4,973,982,900,709.39
It looks like the "Dems" ran an $833 billion deficit, during their 6 years, and the "repubs" have run up a $2,693 billion deficit, in 1-1/2 months less than a most recent, 5 year period.
The trade imbalance is now exactly double what it was in 2001.
The twin deficits are unsustainable, and it is too late to reverse the trend. Oil and commoditites will rise in price as the perception of the value of the dollar will continue to increase the number of dollars that commodity sellers will demand in exchange for their products. There will be no money to invest in alternative energy, as this crisis continues to progress. As the implosion in the domestic economy from the emerging real estate crash, accelerates the decline, you can stick a fork in the US economy and it's dollar....we're done!
August 23, 2006 12:44 PM | Reply | Permalink
Second what LaFollette Prog... says.
Mickey's tedious (his words) response pretty well clarifies that he did not understand the basic point of this Yglesias post.
The research angle is both real and a canard. Assuming no change to the way research is funded this would be a significant problem, but as Dean Baker has shown, this is a ridiculously inefficient way to fund research (also see John Quiggin).
I assume that if this avenue of research funding dried up, it would make it much easier to pursue more efficient and sensible ways of funding research.
August 24, 2006 9:24 AM | Reply | Permalink
What does this have to do with healthcare issues? That's one area of the economy that is fairly impervious to globalization even where people might like it to be otherwise (e.g., drug reimports). So the strength of weakness of the dollar is not very relevant. Maybe you psoted to the wrong thread (something I admit to having done myself)
August 24, 2006 4:58 PM | Reply | Permalink
Bringing millions of young and healthy people who will be net payors into the current system will prop it up handily, not cost it additional money.
August 24, 2006 5:00 PM | Reply | Permalink